Please Note: A red asterisk (*) indicates a required field. "*" indicates required fields Firm InformationFirm Name* Contact Name* Firm Address (including City, State & Zip Code)* Phone Number*Email Address* HiddenInfo BreakAttorneys and EmployeesRepeaterLawyer Name* First Last Florida Bar Number* Number of Years With the Firm*Board Certified?* Yes No Add LawyerRemove LawyerNumber of Non-Lawyer Employees on the Firm*HiddenPractice/Attorney breakPractice InformationCurrently Insured* Yes No If Yes, what is the Retroactive Date? Own a Title Company?* Yes No Limits of Liability per Claim/Total Limit* $100,000/$300,000 $250,000/$500,000 $500,000/$1,000,000 $1,000,000/$1,000,000 Other Deductible* $2,500 $5,000 $10,000 Top Three Counties in Which 30% or More of Your Practice Is Based*1. County Name1. Percentage2. County Name (Optional; if none, type "N/A")2. Percentage (Optional)2. County Name (Optional; if none, type "N/A")3. Percentage (Optional)Percentage of Practice Out of State* Three Major Areas of Practice and Percentages*1. Area of Practice1. Percentage2. Area of Practice (Optional; if none, type "N/A")2. Percentage (Optional)3. Area of Practice (Optional; if none, type "N/A")3. Percentage (Optional)HiddenPractice Info BreakClaims/Discipline InformationNumber of Reported Incidents and/or Claims in Last 5 Years* Number of Disciplinary Proceedings Before Any Bar within the Past 5 Years*HiddenClaims/Discipline Information BreakCAPTCHA Δ
